FACTORS AFFECTING THE RELOCATION AND TRANSITION OF INTERNATIONALLY EDUCATED NURSES MIGRATING TO THE UNITED STATES OF AMERICA by KRISTINA SYLVIA IBITAYO Presented to the Faculty of the Graduate School of The University of Texas at Arlington in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY THE UNIVERSITY OF TEXAS AT ARLINGTON December 2010 Copyright © by Kristina Sylvia Ibitayo 2010 All Rights Reserved ACKNOWLEDGEMENTS While working on a dual MSN/MBA degree it occurred to me that I could obtain my MSN and move straight into a PhD in nursing program. I figured it would only be a few credit hours difference and a little more time investment. I am still smiling at my naivety, but well contented in this God-ordained venture. During my first semester, when asked why I was seeking a PhD in nursing, I spoke my passion, “So that I can be a part of redefining the nursing paradigm in the developing world.” My goal remains unchanged. The education and experiences of the past six years in the PhD nursing program strengthened and intensified my vision of a lifelong career within the global health arena. Foremost, I thank my God for guiding my steps to the University of Texas at Arlington, where I encountered a long-cherished desire, a community of scholars and select mentors who explored varied paths of knowledge with me. From my first semester on, I marveled at the infinity of choice and the rippling effects of each decision made. Attending UT Arlington started me on this beguiling journey of research into factors affecting the relocation and transition of internationally educated nurses. As the Zulus say, Umuntu Ngamantu Ngubantu. I am who I am because of my family and the friends in my life. I thank the following key people: My husband, Femi Ibitayo, who has always dreamed with me, thinks with me, fueling my heart with courage to do that for which I was born; my two sons, Tobeya and Yosef, who are my heroes marching boldly through life, unabashedly using the intellect and multiple talents bestowed them; my father and mother, Stan and Margot McMillen, for giving me my world view by raising their children in Papua New Guinea, Mexico, and Guatemala; and Rev. Panya Baba for facilitating our participation in Rescue Fellowship Nigeria, meeting the needs of the underserved Nigerian population. Thanks to my fellow PhD students and graduates for their support: Dr. Susan Baxley for her steadfast friendship and ready laugh, Dr. Kathy Daniel for her unflappable attitude, Mei- iii Yi Lee for my introduction to Taiwanese nursing and experiences at Kaohsiung Medical University‟s nursing college, Jakki Opollo for her passion on Kenyan healthcare, Lori Spies for her dry wit, and Dr. Gloria Carr for being my Thursday Buddy. I thank my mentors for always believing in me and willingly sharing their expertise with me. Dr. Elizabeth Poster always gave me her time, listened to my ideas, and pleasantly debating them with me, thus solidifying or clarifying my thoughts. Proper statistical analysis is the heart of valuable research - thank you Dr. Daisha Cipher. The three scholars on my dissertation committee are passionate about research and open in expressing their views on my dissertation topic. As iron sharpens iron, their experience and guidance was invaluable throughout this dissertation process. For her expert guidance on internationally educated nurses‟ research and her unwavering research commitment to East African nurses, I thank my dissertation chair, Dr. Jennifer Gray. The breadth of her ready intellect inspires me in my efforts. I thank all members of my dissertation committee for their unflagging support. Dr. Bond, thank you for generously supporting my dissertation research with the Mary Lou Bond Fellowship. I first became interested in UT Arlington because of the Hispanic Center Dr. Bond directs. How fitting it is that she consented to be on my dissertation committee. I thank Dr. Carolyn Cason for speaking words of truth that resonate with me to this day; your words are yours to share. I appreciate how she creatively in condenses and conveys research knowledge in various ways for recall according to each individual‟s learning style. Finally, I am grateful to all of my gatekeepers for contacting internationally educated nurses to participate in this study. Their networks made this research possible. I thank all of the internationally educated nurses who participated in my study for sharing their relocation and transitions experiences with me. Their openness motivates me to continue researching IEN migration issues and assist IENs in their transition experiences. November 8, 2010 iv ABSTRACT FACTORS AFFECTING THE RELOCATION AND TRANSITION OF INTERNATIONALLY EDUCATED NURSES MIGRATING TO THE UNITED STATES OF AMERICA Kristina Sylvia Ibitayo, PhD. The University of Texas at Arlington, 2010 Supervising Professor: Jennifer Gray A paucity of research studies and systematic reviews have been conducted on IEN nurse migration experiences in the US. The number of IENs in the US RN workforce is projected to continue growing. Therefore, studies on nurse migration and IEN relocation and transition experiences are essential. This exploratory descriptive study on the transition conditions and professional satisfaction of nurses migrating to the US provides information on the complex pull and push factors affecting nurse migration. This study described the push factors, pull factors, personal characteristics, motivation to migrate, transition conditions, family/social environment, work environment, and professional satisfaction of IENs in the US health care system. It also described the differences in these IENs across source countries by world region. This study‟s conceptual framework guided the data analysis and exploration of concepts. Results for this study indicated the majority of IENs who received their basic nursing education across all WHO regions experienced high professional satisfaction on all items in the Professional Satisfaction subscale. Although unexpected, this finding may reflect the maturity of v the IENs, as they were not new nurses but filled out the instrument retrospectively. Their memory of their relocation and transition experiences may have lost its immediacy. This research study added to the knowledge base on nurse migration issues by providing a greater understanding of foreign nurses‟ relocation and transition experiences in the US, and the successful integration of foreign nurses from around the world into the healthcare workforce. Several IEN participants indicated in their open-ended comments that they desired transition programs both in their source countries and their destination countries. Individualized IEN transition programs could be developed with modular components and content on clinical practice, organizational environment, and IEN specific issues such as state board registration and seminars on communication issues, workplace ethics, and how to handle workplace issues such as discrimination. It is hoped that as IENS relocate to the US and transition into the healthcare environment, they will experience increased professional satisfaction. vi TABLE OF CONTENTS ACKNOWLEDGEMENTS…………………………….………………………………………… iii ABSTRACT………………………………………………………………………………………. v LIST OF ILLUSTRATIONS…………………………………………………………………….. xii LIST OF TABLES……………………………………………………………………………….. xiii Chapter Page 1. INTRODUCTION…………………………….…………………………………… 1 Background and Significance……………………………..…….……. 1 Demographics of Migration…………………………………. 2 Processes of Migration ……………..……………………………. 3 Reasons of Migration ………………………………………………. 8 Conceptual Framework……………………………..………………… 11 Conceptual Definitions ………….…………………………….……… 12 Purpose of the Study ………….………………………….………..… 14 Research Questions ………….………………………….…………… 14 Assumptions ………….………………………….………………….… 15 Chapter Summary ………….……………….……………………...… 15 2. REVIEW OF RELEVANT LITERATURE ………………………………………… 16 Background…………………………..………….…….……………….. 16 Statistical Picture…………..………..………….…….……………….. 17 Ethics of Nurse Migration…………..………..……….……………….. 18 Nurse Migration Thought Leaders..………….……..……………….. 19 Brush……………..……………………………………………. 19 vii Kingma……………..………….………………………………. 20 Buchan……………..…………………………………………. 20 Aiken……………..………….…………………………………. 20 Buerhaus……………..………………………………….……. 21 Stilwell……………..………………………………….………. 21 Blythe and Baumann…………………………….………….. 22 Historical Patterns of Nurse Migration…..………..………..………… 22 United States…………..……………...………….…….…….. 23 Other Countries…………..…….……..………….………….. 26 Motivation to Migrate…..………..………..…………………………… 26 Work Satisfaction and Employment Setting……………..………….. 28 Transition Experiences…………….………….……..……………..….. 30 Summary of Literature Review…………….………….……..………..… 35 3. METHODS AND PROCEDURES……………………………………………. 36 Research Design…………………..…………………………………… 36 Sample………….…………………………………………………….… 36 Sampling Method and Key Gatekeeper Characteristics……………………………………………..…. 37 Measurement Methods………….………………..………………….… 38 Instrument Validity…………………………………………….. 39 Instrument Reliability…………………………………………… 40 Sources of Data……………………………………………..…. 40 Procedures……………………….………………..………………….… 41 Flow Chart of Data Collection Process………..………..…. 42 Flow Chart of Data Preparation Process……………….…. 43 viii Ethical Considerations………………….………………..…………….… 43 Review Process………..………………………………….…. 43 Risk/Benefit Ratio…………………………….…………….…. 44 Statistical Analyses Used for Sample Description……..………….… 44 Data Analyses Used to Answer Research ……………………………. 45 Scoring of Quantitative Items…………………………….….